The use of fresh frozen plasma for reproduction in severe factor V deficiency.

OBJECTIVE: Severe factor V (FV) deficiency is rare. There are case reports describing pregnancy outcomes in women with FV deficiency and one case report of successful pregnancy following the use of fresh frozen plasma (FFP) in several cycles of ovulation induction and intrauterine insemination and at delivery. The authors report another case to support the use of FFP for reproduction. CASE: A 27-year-old woman with severe FV deficiency was given FFP at the time of ovulation induced with clomiphene citrate, human menopausal gonadotropin (hMG), and human chorionic gonadotropin. Intrauterine insemination (IUI) was done 35 hours later. She became pregnant with twins and delivered vaginally at 36 weeks of gestation with the prophylactic use of FFP. CONCLUSION: Fresh frozen plasma can be offered for reproduction to women with severe FV deficiency.

High prevalence of vitamin D deficiency among healthy Saudi Arabian men: relationship to bone mineral density, parathyroid hormone, bone turnover markers, and lifestyle factors.

SUMMARY: In this cross-sectional study, the prevalence of vitamin D deficiency [serum 25-hydroxyvitamin D (25(OH)D) <50 nmol/L] was 87.8% among Saudi Arabian men. There was a linear inverse relationship between serum 25(OH)D and intact parathyroid hormone (PTH) levels, but without a threshold of 25(OH)D at which intact PTH values plateaued. INTRODUCTION: Vitamin D insufficiency and/or deficiency has now reached epidemic proportions and has been linked to low bone mineral density (BMD), some lifestyle factors, and obesity in adults. This relationship is not well documented in Saudi Arabian men. This study examines the relationship between vitamin D status, intact parathyroid hormone (intact PTH), and lifestyle factors among Saudi Arabian men. METHODS: This cross-sectional study involved 834 men aged 20-74 years living in Jeddah area who were randomly selected and medically examined. Men had their BMD (lumbar spine (L1-L4) and neck femur), 25(OH)D, intact PTH, and other parameters measured according to detailed inclusion criteria. RESULTS: Deficiency (25(OH)D<50 nmol/L) and insufficiency (≥50-75 nmol/L) were present in 87.8% and 9.7%, respectively. Deficiency was common among older and obese men with no education and sedentary lifestyle sampled during summer and spring. Serum 25(OH)D showed an inverse linear relationship with intact PTH, but there was no threshold of serum 25(OH)D at which PTH levels plateaued. There was a positive correlation between BMD values at both lumbar spine (L1-L4) (P < 0.023) and neck femur (P < 0.036) and serum 25(OH)D levels, respectively. CONCLUSIONS: Functionally significant vitamin D deficiency affects BMD and bone turnover markers among Saudi Arabian men and is largely attributed to older age, obesity, sedentary lifestyle, no education, poor exposure to sunlight, smoking, and poor dietary vitamin D supplementation. The data suggest that an increase in PTH cannot be used as a marker for vitamin D deficiency.

Decreased serum sclerostin levels in patients with primary hyperparathyroidism: a cross-sectional and a longitudinal study.

UNLABELLED: Decreased serum sclerostin was evident in patients with primary hyperparathyroidism and was inversely related to parathyroid hormone (PTH). Sclerostin normalized earlier than biochemical bone turnover markers (BTMs) following parathyroidectomy. INTRODUCTION: There is limited information on the changes of serum sclerostin in conditions with chronic PTH excess in humans. The main objectives of the present study were to: (1) examine cross-sectionally the changes of serum sclerostin levels in patients with primary hyperparathyroidism (PHPT), (2) study the time course changes in serum sclerostin in PHPT patients following parathyroidectomy (PTX) followed up longitudinally for 12 months, and (3) compare the changes in serum sclerostin to that of BTMs. METHODS: We studied 60 PHPT patients and compared them with 74 PTX patients together with 268 age- and sex-matched healthy controls. Also, we followed 27 PTX patients longitudinally at 2, 4, 6, 10, 30, 60, 180, and 360 days postoperatively. Serum sclerostin, BTMs, and minerals were measured. Also, bone mineral density was determined by dual energy X-ray absorptiometry. RESULTS: Patients with PHPT exhibited significantly lower mean serum sclerostin [mean, in picomoles per liter; 95% confidence interval (CI)] (28.98; 27.94-30.03) than that obtained for PTX patients (37.01; 35.75-38.27) and healthy controls (46.22; 45.13-47.31) (P < 0.0001, for each case), respectively. Serum PTH inversely correlated with serum sclerostin (r = -0.651, P < 0.0001). Serum sclerostin was normalized in PTX patients by the tenth day postoperatively and remained within the expected reference range thereafter. CONCLUSIONS: Significantly decreased serum sclerostin was evidenced in PHPT patients as compared with PTX and euparathyroid controls. The inverse PTH and sclerostin relationship suggests that sclerostin is downregulated by PTH in humans. Serum sclerostin normalized earlier than BTMs following parathyroidectomy.

Vitamin D status in relation to obesity, bone mineral density, bone turnover markers and vitamin D receptor genotypes in healthy Saudi pre- and postmenopausal women.

UNLABELLED: The various factors that may contribute to vitamin D deficiency or insufficiency were examined among healthy Saudi pre- and postmenopausal women. Vitamin D deficiency was highly prevalent among studied Saudi women with obesity, poor sunlight exposure, poor dietary vitamin D supplementation and age as the main risk factors. INTRODUCTION: The various factors that may contribute to vitamin D deficiency or insufficiency in relation to bone health among Saudi women are not known. The main objectives of the present study were to determine the factors influencing vitamin D status in relation to serum 25-hydroxyvitamin D (25(OH)D), intact parathyroid hormone (PTH), bone turnover markers (BTMs), bone mineral density (BMD), and vitamin D receptor genotype (VDR) in healthy Saudi pre- and postmenopausal women. METHODS: A total number of 1,172 healthy Saudi women living in the Jeddah area were randomly selected and studied. Anthropometric parameters, socioeconomic status, sun exposure index together with serum levels of 25(OH)D, calcitriol, intact PTH, Ca, PO4, Mg, creatinine, albumin, and biochemical BTMs were measured. BMD was measured by a dual energy X-ray absorptiometry and VDR genotypes were also determined. RESULTS: About 80.0% of Saudi women studied exhibited vitamin D deficiency (serum 25(OH)D<50.0 nmol/L) with only 11.8% of all women were considered with adequate vitamin D status (serum 25(OH)D>75 nmol/L). Secondary hyperparathyroidism was evident in 18.5% and 24.6% in pre- and postmenopausal women with 25(OH)D<50 nmol/L. Serum 25(OH)D was lower (P<0.001) and intact PTH higher (P<0.001) in the upper quintiles of body mass index (BMI) and waist-to-hip ratio (WHR). Multiple linear regression analysis showed that BMI, sun exposure index, poor dietary vitamin D supplementation, WHR, and age were independent positive predictors of serum 25(OH)D values. CONCLUSIONS: Vitamin D deficiency is highly prevalent among healthy Saudi pre-and postmenopausal women and largely attributed to obesity, poor exposure to sunlight, poor dietary vitamin D supplementation, and age.

Lycopene nanoparticles promotes osteoblastogenesis and inhibits adipogenesis of rat bone marrow mesenchymal stem cells.

OBJECTIVE: Lycopene is a carotenoid and antioxidant with potent singlet oxygen quenching ability that reduces oxidative stress and promotes bone health. However, the cellular mechanisms by which lycopene influences bone metabolism are not known. MATERIALS AND METHODS: The present study investigated the effects of lycopene nanoparticles on the differentiation of rat bone marrow-derived mesenchymal stem cells into osteoblasts or adipocytes. RESULTS: In osteogenic medium, lycopene supplementation dose-dependently enhanced osteoblast differentiation, as evidenced by the transcription of Alpl, Runx2, Col1a1, Sp7, and Bglap, higher alkaline phosphatase activity, osteocalcin secretion and extracellular matrix mineralisation seen with Alizarin red S staining, and increased haem oxygenase levels. By contrast, lycopene in adipogenic medium inhibited adipocyte differentiation evidenced by decreases in the transcription of Tnfsf11, Tnfrsf11b, Pparg, Lpl, and Fabp4 and reduced fat accumulation observed by Oil Red O staining. CONCLUSIONS: Lycopene nanoparticles may promote bone health and are considered as a potential candidate for the prevention and/or treatment of bone loss conditions.

The effect of cigarette or sheesha smoking on first-trimester markers of Down syndrome.

OBJECTIVE: To investigate the influence of cigarette or sheesha smoking on first-trimester markers of Down syndrome. DESIGN: A prospective observational study. SETTING: Primary care centres and antenatal clinics of Maternity and Children Hospital, King Abdulaziz University Hospital and New Jeddah Clinic Hospital, Jeddah, Saudi Arabia. POPULATION: Women with a singleton pregnancy who were either nonsmokers (n = 1736) or cigarette smokers (n = 420) or sheesha smokers (n = 181). METHODS: Fetal nuchal translucency thickness (fetal NT), maternal serum free beta-human chorionic gonadotrophin (free beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) were measured at 11 weeks 0 days to 13 weeks 6 days of gestation in all women. Women were grouped according to smoking status, confirmed by maternal serum cotinine measurements, and analyte levels between groups were compared. MAIN OUTCOME MEASURES: Fetal NT, maternal serum free beta-hCG, PAPP-A and cotinine measurements. RESULTS: Compared with nonsmoking women, fetal NT was significantly increased and free beta-hCG and PAPP-A levels were significantly decreased in both cigarette and sheesha smokers. There were significant relationships between all three markers and the number of sheeshas consumed per day. CONCLUSIONS: Cigarette and sheesha smoking significantly affect first-trimester markers of Down syndrome (fetal NT, free beta-hCG and PAPP-A). Correction for this effect in women who smoke might improve the effectiveness of first-trimester screening for Down syndrome in these women. The underlying mechanism(s) relating smoking to the changes in first-trimester markers require further studies.

High throughput coagulation analyzers review.

The increasing no. of ordered coagulation screening tests has led to a remarkable improvement in the efficiency of automated coagulation testing, and appearance of a new generation of high throughput analyzers ensuring accuracy and precision, and reducing the strain and human error. The earliest analyzers operated mechanically, using the hook to detect the clot in the cuvette are now replaced with more sophisticated analyzer that simultaneously uses the clotting, chromogenic, and immunological principles, to provide a versatile test menu covering antigenic and functional aspects of coagulation. The armamentarium of coagulation testing is complimented with tools like; automated platelet function analyzer, flowcytometer, and molecular techniques including the polymerase chain reaction, and lately the microarrary (biochip) technology. This review addresses the principle of operation and distinctive features of various automated high throughput coagulation analyzers, their impact on improving efficiency, eliminating preanalytical and postanalytical handling thus maximizing productivity and return on investment.

Immunophenotyping of childhood acute lymphoblastic leukemia in Saudi Arabia: second look.

Geographical variations in the incidence of disease are of considerable theoretical and practical importance. It has been claimed that the distribution of acute lymphoblastic leukemia (ALL) phenotypes in Saudi Arabia is different from that recorded in the Western literature. One hundred and twelve (112) patients under 15 years of age, diagnosed as ALL between January 1992 and May 1994 had immunophenotypes performed on their blast cells. Common ALL (cALL) together with pre-B-ALL, formed 86.5% of the total; B-cell 3%, T-cell 6% and null cell 4.5%. These figures are not significantly different from the Western literature. A previous claim from this institution in 1990, that both null and B-cell ALL were significantly increased compared with elsewhere, is not supported by the present figures. Age and sex distribution, and FAB classification, L1 77%, L2 20% and L3 3%, were also of the same order as described elsewhere and, in particular, there was no increase in the frequency of L3 subtype.

The Sebastian platelet syndrome. Report of the first native Saudi Arabian patient.

Sebastian platelet syndrome is an hereditary thrombocytopenia with giant platelets and inclusion bodies in the granulocytes consisting of dispersed filaments, clusters of ribosomes and a few segments of rough and smooth endoplasmic reticulum at the ultrastructural level, similar to those observed in Fechtner syndrome (a variant of the Alport syndrome)--Sebastian platelet syndrome lacks the additional clinical features such as high frequency deafness, congenital cataract, and chronic interstitial nephritis. Here we report the fourth case worldwide and the first of an Arabian ancestry.

International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer.

BACKGROUND: Guidelines addressing the management of venous thromboembolism (VTE) in cancer patients are heterogeneous and their implementation has been suboptimal worldwide. OBJECTIVES: To establish a common international consensus addressing practical, clinically relevant questions in this setting. METHODS: An international consensus working group of experts was set up to develop guidelines according to an evidence-based medicine approach, using the GRADE system. RESULTS: For the initial treatment of established VTE: low-molecular-weight heparin (LMWH) is recommended [1B]; fondaparinux and unfractionated heparin (UFH) can be also used [2D]; thrombolysis may only be considered on a case-by-case basis [Best clinical practice (Guidance)]; vena cava filters (VCF) may be considered if contraindication to anticoagulation or pulmonary embolism recurrence under optimal anticoagulation; periodic reassessment of contraindications to anticoagulation is recommended and anticoagulation should be resumed when safe; VCF are not recommended for primary VTE prophylaxis in cancer patients [Guidance]. For the early maintenance (10 days to 3 months) and long-term (beyond 3 months) treatment of established VTE, LMWH for a minimum of 3 months is preferred over vitamin K antagonists (VKA) [1A]; idraparinux is not recommended [2C]; after 3-6 months, LMWH or VKA continuation should be based on individual evaluation of the benefit-risk ratio, tolerability, patient preference and cancer activity [Guidance]. For the treatment of VTE recurrence in cancer patients under anticoagulation, three options can be considered: (i) switch from VKA to LMWH when treated with VKA; (ii) increase in LMWH dose when treated with LMWH, and (iii) VCF insertion [Guidance]. For the prophylaxis of postoperative VTE in surgical cancer patients, use of LMWH o.d. or low dose of UFH t.i.d. is recommended; pharmacological prophylaxis should be started 12-2 h preoperatively and continued for at least 7-10 days; there are no data allowing conclusion that one type of LMWH is superior to another [1A]; there is no evidence to support fondaparinux as an alternative to LMWH [2C]; use of the highest prophylactic dose of LMWH is recommended [1A]; extended prophylaxis (4 weeks) after major laparotomy may be indicated in cancer patients with a high risk of VTE and low risk of bleeding [2B]; the use of LMWH for VTE prevention in cancer patients undergoing laparoscopic surgery may be recommended as for laparotomy [Guidance]; mechanical methods are not recommended as monotherapy except when pharmacological methods are contraindicated [2C]. For the prophylaxis of VTE in hospitalized medical patients with cancer and reduced mobility, we recommend prophylaxis with LMWH, UFH or fondaparinux [1B]; for children and adults with acute lymphocytic leukemia treated with l-asparaginase, depending on local policy and patient characteristics, prophylaxis may be considered in some patients [Guidance]; in patients receiving chemotherapy, prophylaxis is not recommended routinely [1B]; primary pharmacological prophylaxis of VTE may be indicated in patients with locally advanced or metastatic pancreatic [1B] or lung [2B] cancer treated with chemotherapy and having a low risk of bleeding; in patients treated with thalidomide or lenalidomide combined with steroids and/or chemotherapy, VTE prophylaxis is recommended; in this setting, VKA at low or therapeutic doses, LMWH at prophylactic doses and low-dose aspirin have shown similar effects; however, the efficacy of these regimens remains unclear [2C]. Special situations include brain tumors, severe renal failure (CrCl<30 mL min(-1) ), thrombocytopenia and pregnancy. Guidances are provided in these contexts. CONCLUSIONS: Dissemination and implementation of good clinical practice for the management of VTE, the second cause of death in cancer patients, is a major public health priority.

International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer.

BACKGROUND: Although long-term indwelling central venous catheters (CVCs) may lead to pulmonary embolism (PE) and loss of the CVC, there is lack of consensus on management of CVC-related thrombosis (CRT) in cancer patients and heterogeneity in clinical practices worldwide. OBJECTIVES: To establish common international Good Clinical Practices Guidelines (GCPG) for the management of CRT in cancer patients. METHODS: An international working group of experts was set up to develop GCPG according to an evidence-based medicine approach, using the GRADE system. RESULTS: For the treatment of established CRT in cancer patients, we found no prospective randomized studies, two non-randomized prospective studies and one retrospective study examining the efficacy and safety of low-molecular-weight heparin (LMWH) plus vitamin K antagonists (VKAs). One retrospective study evaluated the benefit of CVC removal and two small retrospective studies were on thrombolytic drugs. For the treatment of symptomatic CRT, anticoagulant treatment (AC) is recommended for a minimum of 3 months; in this setting, LMWHs are suggested. VKAs can also be used, in the absence of direct comparisons of these two types of anticoagulants in this setting [Guidance]. The CVC can be kept in place if it is functional, well-positioned and non-infected and there is good resolution under close surveillance; whether the CVC is kept or removed, no standard approach in terms of AC duration has been established [Guidance]. For the prophylaxis of CRT in cancer patients, we found six randomized studies investigating the efficacy and safety of VKA vs. placebo or no treatment, one on the efficacy and safety of unfractionnated heparin, six on the value of LMWH, one double-blind randomized and one non randomized study on thrombolytic drugs and six meta-analyses of AC and CVC thromboprophylaxis. Type of catheter (open-ended like the Hickman(®) catheter vs. closed-ended catheter with a valve like the Groshong(®) catheter), its position (above, below or at the junction of the superior vena cava and the right atrium) and method of placement may influence the onset of CRT on the basis of six retrospective trials, four prospective non-randomized trials, three randomized trials and one meta-analysis. In light of these data: use of AC for routine prophylaxis of CRT is not recommended [1A]; a CVC should be inserted on the right side, in the jugular vein, and distal extremity of the CVC should be located at the junction of the superior vena cava and the right atrium [1A]. CONCLUSION: Dissemination and implementation of these international GCPG for the prevention and treatment of CRT in cancer patients at each national level is a major public health priority, needing worldwide collaboration.

Biomarkers of inflammation, growth factor, and coagulation activation in patients with sickle cell disease.

Acute painful crisis is a common sequela that can cause significant morbidity and negatively impact the quality of life of patients with sickle cell disease (SCD). Plasma levels of several chemokines and cytokines including tumor necrosis factor-α (TNF-α), interleukin 1ß (IL-1ß), IL-6, IL-8, monocyte chemoattractant protein 1 (MCP-1), macrophage inflammatory protein 1α (MIP-1α), and interferon γ (IFN-γ) in patients with SCD showed a distinct and statistically significant rise either during painful crisis or at steady state. Plasma levels of various growth factors, including human vascular endothelial growth factor (VEGF), human basic fibroblast growth factor (FGF), and human hepatocyte growth factor (HGF), showed a sustained 2- to 3-fold increase either during painful crisis or at steady state in patients with SCD. Furthermore, plasma levels of the biomarker d-Dimer, a marker of hypercoagulation, showed a 2- to 3-fold increase either during painful crisis or at steady state in patients with SCD as compared to that in healthy participants, suggesting an increased risk of thrombosis.

Mutation of p16, p21 or cyclin dependent kinase 4 is rare in acute lymphoblastic leukaemia.

Homozygous deletion of the p16 tumour suppressor gene (at frequencies ranging from 14% to 29%) have been implicated in the pathogenesis of acute lymphoblastic leukaemia (ALL) by several studies. We investigated the prevalence of this deletion in a group of 46 Arab patients with common ALL. Deletion of p16 was assessed in a multiplex PCR which amplified a 405 bp fragment from exon 2 of the p16 gene, and a 242 bp fragment of the ApoE lipoprotein gene which served as an internal control. Homozygous deletion of p16 in tumour cells could be readily detected in samples containing >75% blasts. Surprisingly, none of the cases in our study showed homozygous deletion of the p16 gene. We also investigated the possibility of other genetic alterations in the p16 gene or mutation in the p21 and CDK4 (not previously reported in ALL) genes which are part of the same signal transduction pathway. A heterozygous G --> A transition at nucleotide position 273 of the p16 gene was present in one patient, but did not result in an amino acid change. A C --> A transversion at codon 88 of the p21 gene, which results in replacement of a phenylalanine with a leucine at position 63, was detected in one patient. In another patient a G --> C transversion in exon 2 at codon 82 (5'-untranslated region of the CDK4 gene) was detected. Results of this study showed mutation of p16, p21 or CDK4 to be rare events in Arab ALL patients.