Serotypes of Streptococcus pneumoniae in Egyptian children: are they covered by pneumococcal conjugate vaccines?

In Egypt, pneumococcal vaccines have not yet been introduced as being compulsory. Identification of the circulating serotypes in Egypt is mandatory to determine whether or not the pneumococcal vaccines will be beneficial. The current study aims to identify the serotypes, vaccine coverage, and antimicrobial resistance of Streptococcus pneumoniae colonizing the nasopharynx of Egyptian children younger than 5 years old. The study was conducted in two successive winter seasons (December 2012-February 2013 and December 2013-February 2014). Two hundred children were enrolled, aged from 6 months to 5 years, excluding those with fever, signs of infection, history of antibiotic intake, and hospitalization in the preceding month. Nasopharyngeal (NP) secretions were collected, subjected to culture, and underwent antibiotic susceptibility testing if positive for pneumococci. Real-time polymerase chain reaction (PCR) and serotyping by sequential multiplex PCR for positive cases were included as well. Streptococcus pneumoniae was isolated from 62 subjects. All isolates were sensitive to vancomycin and levofloxacin, but the majority showed resistance to multiple antibiotics. PCR was positive for pneumococci in 113 subjects (56.5%). The most commonly detected serotypes (st) were 6A6B6C (n = 21, 20.8%), 19F (n = 19, 18.8%), 1 (n = 11, 10.9%), 34 (n = 8, 7.9%), and 19A (n = 6, 5.9%). The theoretical coverage of the PCV13 vaccine for the detected serotypes was 72.4%, while that of PCV10 was 65.5%. Based on these percentages, we recommend including pneumococcal conjugate vaccines in the Egyptian national vaccination program.

Three-dimensional sonohysterography compared with vaginoscopic hysteroscopy for evaluation of the uterine cavity in patients with recurrent implantation failure in in vitro fertilization cycles.

STUDY OBJECTIVE: To estimate the degree of agreement between 3-dimensional sonohysterography (3D-SHG) and vaginoscopic hysteroscopy (VH) in detection of uterine cavity abnormalities in patients with recurrent implantation failure in in vitro fertilization cycles. DESIGN: Comparative observational cross-sectional study (Canadian Task Force classification II-1). SETTING: Private assisted-conception unit. PATIENTS: One hundred forty-three patients with a history of at least 2 previous implantation failures despite transfer of good quality embryos in assisted-conception cycles. INTERVENTIONS: 3D-SHG was followed by VH. The Cohen κ for interrater agreement was calculated for the level of agreement between the 2 diagnostic procedures. Procedure time in seconds was recorded for both procedures. Patients were asked to rate their degree of discomfort or pain during both procedures using a visual analog scale. MEASUREMENTS AND MAIN RESULTS: There was a substantial degree of concordance between 3D-SHG and VH (κ = 0.77; 95% confidence interval, 0.6-0.84). The median procedure time for 3D-SHG was 296 seconds (range, 231-327 seconds), and for VH was 315 seconds (range, 232-361 seconds), and the difference was statistically significant (p =.02). The visual analog scale pain scores also showed that 3D-SHG, with a median pain score of 2.1 (range, 1-3) was better tolerated than VH, with a median pain score of 2.9 (range, 2-4) (p < .001). CONCLUSION: Our results show that there is a substantial degree of concordance between 3D-SHG and VH in diagnosing uterine cavity anomalies. We also found that 3D-SHG took significantly less time and induced less patient discomfort than did VH. We recommend that 3D-SHG should be the method of first choice for outpatient evaluation of the uterine cavity.

CD209-336A/G promotor polymorphism and its clinical associations in sickle cell disease Egyptian Pediatric patients.

OBJECTIVES: To detect the frequency of CD209 A>G polymorphism in sickle cell disease (SCD) Egyptian patients and to evaluate the use of CD209 A>G polymorphism as a genetic predictor of SCD clinical heterogeneity. METHODS: A total of 100 Egyptian children with SCD and 100 Egyptian controls were tested for CD209 A>G polymorphism and were followed up prospectively between June 2012 and December 2014. RESULTS: Comparison of CD209 A>G polymorphism among cases and controls did not show statistically significant difference (p = .742). In addition, comparison of the allelic frequency did not show statistically significant difference (p = .738). Infections occurred more frequently among the heterozygous genotype (AG; 60.5%) and homozygous genotype (GG; 75%) patients than among the wild (AA) genotype (24.1%; p < .001). The use of hydroxyurea treatment was significantly higher among the wild (AA) genotype (47%) than the heterozygous (AG; 21%) and homozygous (GG; 5%) genotypes (p = .003). CONCLUSION: We found no significant difference between our population of Egyptian SCD cases and controls regarding CD209 A>G polymorphism. Infections occurred more frequently among the heterozygous genotype (AG) and homozygous genotype (GG) patients.

V-Y dorsal metacarpal flap: a new technique for the correction of syndactyly without skin graft.

A new technique for web reconstruction in congenital syndactyly is described. Twenty-one web spaces in 12 patients were treated using this method. The dorsal metacarpal flap was used as an island V-Y advancement to cover the newly created web space, thus avoiding skin graft in this space. A follow-up of 6 months to 2 years showed neither recurrence of the deformity nor web creep of any degree. The operation is rapid, easy, and reproducible. It is suggested that this technique can be used in all types of syndactyly.

Changes in some blood constituents of Barki ewes during pregnancy and lactation under semi arid conditions.

A study based on 12 pregnant and six dry Barki ewes was carried out to examine the changes in blood constituents during pregnancy and lactation periods. The blood parameters were blood hemoglobin, packed cell volume percent (PCV%), mean corpuscular hemoglobin concentration (MCHC), glucose, aspartate aminotransaminase (AST or GOT), alanine aminotransaminase (ALT or GPT), total plasma protein, albumin, globulin, albumin to globulin ratio (A/G), urea and creatinine. During pregnancy all these parameters started to increase significantly, but in different stages, reaching maximum values at parturition. In contrast, dry ewes showed almost stable values during the experimental period. From 10th week to parturition, PCV% and MCHC increased (P<0.01) in pregnant ewes, which resulted in increased (P<0.01) blood hemoglobin. Blood glucose increased from the 4th week of pregnancy to reach its maximum at parturition (60.15-90.08mg/dl). The two transaminases increased significantly from the 2nd week (52.23-65.02IU for AST and 8.02-15.12IU for ALT). Plasma protein with its two components, albumin and globulin, increased significantly at the 6th week, but dropped throughout the 16-18th week of pregnancy. Urea and creatinine began to increase significantly after 10-12 weeks of pregnancy (from 54.73 to 72.11mg/dl for urea and from 0.882 to 2.475mg/dl for creatinine). During the first month of lactation, PCV decreased sharply in lactating ewes and was significantly lower than in dry ewes at the 3rd week of lactation (24.25 versus 27.17%), which resulted in a drop in blood hemoglobin at the 4th week (68.42 versus 74.00g/l). However, lactating ewes maintained significantly higher values of MCHC (30.01-31.19% for lactating versus 29.87-27.48% for dry). In lactating ewes, levels of glucose, ALT, urea and creatinine returned to levels comparable to those in dry ewes. The same occurred with total plasma proteins, mainly due to a sharp decrease in globulin, while albumin remained higher than in dry ewes with a slow decline, which resulted in higher values of A/G ratio during lactation. Aspartate aminotransferase remained higher than in dry ewes.

Validation of a proposed warfarin dosing algorithm based on the genetic make-up of Egyptian patients.

BACKGROUND: Warfarin is the most frequently prescribed oral anticoagulant worldwide. Due to its narrow therapeutic index and inter-patient variability in dose requirement, this drug has been considered an ideal target for personalised medicine. Several warfarin dosing algorithms have been proposed to tailor the warfarin dosage in the European, Asian and African-American populations. However, minimal interest was directed towards Middle East countries. The factors affecting warfarin dose requirement could be different in patients from different geographical and ethnic groups, limiting the value of published dosing algorithms. OBJECTIVE: The first objective of this study was to examine the contribution of genetic and nongenetic factors on the variability of warfarin dose requirements in the Egyptian population using an easy, cost-effective and rapid analysis of vitamin K epoxide reductase complex subunit 1 (VKORC1) and cytochrome P450 (CYP) 2C9 single nucleotide polymorphism (SNP) genotyping of patients. A second objective was to develop and validate an algorithm for warfarin dose prediction that is tailored to Egyptian patients. METHODS: Eighty-four patients, 41 males and 43 females, with a median (25th-75th percentiles) age of 39 (31-48) years were recruited in this study. Fifty patients whose international normalised ratio (INR) was in the range of 2-3 were allocated to a study cohort. SYBR Green-based multiplex allele-specific real-time PCR was used for genotyping of CYP2C9 (1075A>C) and VKORC1 (1173C>T) polymorphisms. Linear regression analysis, including the variables age, gender, CYP2C9 and VKORC1 SNP genotypes, was run to derive the best model for estimating the warfarin dose that achieves an INR of 2-3. The new warfarin dosing algorithm was examined in a second cohort of patients (n=34) to check its validity. The predicted dose requirements for a subgroup of our patients were calculated according to Gage and International Warfarin Pharmacogenetics Consortium (IWPC) algorithms available at http://www.warfarindosing.org. RESULTS: In the study cohort, warfarin dose/week in VKORC1 TT subjects was statistically significantly lower than in VKORC1 CC/CT subjects (p=0.032), while there was no statistically significant difference in warfarin dose/week between CYP2C9*1*1 and *1*3 (p=0.925). A multivariate stepwise linear regression analysis revealed that age and VKORC1 had independent and significant contributions to the overall variability in warfarin dose with a p-value=0.013 and 0.042, respectively. Maintenance dose (mg/week)=65.226-0.422×(age) - 9.474×(VKORC1). The estimated regression equation was able to account for 20.5% of the overall variability in warfarin maintenance dose. A significant positive correlation, with sufficient strength, was observed between the predicted warfarin dose and the actual prescribed dose (r=0.453, p=0.001). In the validation cohort, after application of the dosing algorithm, correlation between predicted and actual dose was statistically significant (p=0.023). The equation was particularly successful among patients with a dose≥35 mg/week. The correlation coefficient between the actual and predicted doses for IWPC and Gage were 0.304 and 0.276, respectively. When compared with our algorithm (r=0.279), the difference was non-significant: p=0.903 and 0.990, respectively. CONCLUSION: VKORC1 (1173C>T) contributes to the warfarin dose variability. Patients' age and genetic variants of VKORC1 account for nearly 20.5% of the variability in warfarin dose required to achieve an INR of 2-3. The success of a prediction equation based on these variables was proved in a different cohort: the predicted dose correlated significantly with the maintenance dose and the equation was more successful among patients with a dose≥35 mg/week. The results of the warfarin algorithm we developed were comparable with those of the IWPC and Gage algorithms with the advantage of using one SNP (VKORC1 1173C>T) only. This represents an economic advantage in our community. Replication of this study in a larger cohort of patients is necessary before translation of this knowledge into clinical guidelines for warfarin prescription.

First dorsal metacarpal artery flap in hand reconstruction. I. Anatomical study.

Twenty-one human hands were dissected to study the anatomy of the first dorsal metacarpal artery (FDMA). The artery was found in all the dissected hands. It constantly gave three fascial branches: a radial branch, an ulnar branch, and an intermediate branch. A cutaneous branch was also observed, which may arise either from the radial artery or from the FDMA. It runs with the radial nerve supplying dorsal hand skin. This branch may supplement the vascularization of FDMA flap. The FDMA supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint.

First dorsal metacarpal artery flap in hand reconstruction. II. Clinical application.

The first dorsal metacarpal artery flap was used in 23 patients for coverage of soft tissue hand defects. This flap was used as a fasciocutaneous flap or as a fascial flap. Vascularized periosteum or tendon can also be raised with the flap.

Severe thermal hand burns--factors affecting prognosis.

This paper presents the results of the analysis of clinical data from a series of 132 thermally injured patients with 214 burned hands. The objective was to identify the factors affecting the pathogenesis of postburn hand deformities. The study indicates that deep burns have the worst prognosis and that circumferential burns are always followed by secondary sequelae. The incidence of secondary hand deformity rises sharply when the burn affects more than 25 per cent of the total body surface area (TBSA). Given the same physical therapy programme, early tangential excision and immediate grafting yield better results than conservative treatment. The results underline the role of patient motivation in maximal hand rehabilitation.

Management of tissue breakdown and exposure associated with orbital hydroxyapatite implants.

A new surgical approach for the management of tissue breakdown and exposure of an orbital hydroxyapatite (HA) implant is presented. The implant was placed after evisceration of an atrophic globe. Tissue breakdown and exposure developed 3 weeks after implantation. After a 3-month waiting period for spontaneous healing, a pedicled conjunctival flap from the lower eyelid was fashioned to cover the defect. This technique can be used to cover conjunctival defects over HA implants and is specifically recommended for large defects.

Serum inhibitory factor in lepromatous leprosy: its effect on the pre-S-phase cell-cycle kinetics of mitogen-stimulated normal human lymphocytes.

The sera of ten Egyptian man with long-standing lepromatous leprosy (LL) (mean duration 17.4 years) that had failed to respond to dapsone treatment were shown to inhibit mitogen stimulation responses of normal human lymphocytes. When first tested, the sera partly inhibited the response to phytohaemagglutinin (PHA) and pokeweed mitogen and virtually abolished that to concanavalin A (Con A): after repeated freezing and thawing, the Con A inhibition had disappeared, whereas the PHA response was still partly inhibited. The inhibitory serum factor(s) had similar actions on lymphocytes from each of six normal donors. Although the sera varied in potency, they showed similar dose-response curves when tested against lymphocytes from a single donor. The principal action of the sera was to reduce the number of cells responding to mitogen, without modifying the kinetics of recruitment or rate of volume growth during G1-phase in those cells that were unaffected by the inhibitory substances(s). Study of PHA dose-response curves and of the effect of delayed addition of LL serum suggested that the serum factor(s) act by diminishing the responsiveness of the cells, rather than by reducing the concentrations of free mitogen or by blocking cell membrane mitogen receptors. The serum from one apparently healthy attendant, who had nursed leprosy patients for 30 years but who did not have leprosy or other chronic infective disease, inhibited completely stimulation by all three mitogens in a manner different from that of LL sera. Serum from the other 13 control patients did not modify the response of normal lymphocytes to stimulation by any of the three mitogens studied. It was concluded that the inhibitory factor(s) in the serum of patients with LL were a consequence of the disease and not of the environment in which the patients lived. Microscopy confirmed that the techniques used for recovery of the cultured cells did not introduce bias into the volume spectroscopy measurements.

Hepatitis B virus infection in upper and lower Egypt.

The relative prevalence of hepatitis B surface antigen (HBsAg), anti-HBs, and anti-hepatitis B virus core antigen (HBc), as markers of hepatitis B virus infection, among 1,866 apparently healthy residents of two Egyptian provinces representing Upper and Lower Egypt populations was determined using solid-phase radioimmunoassay (SPRIA). The prevalence rate of HBsAg in the Egyptian population was moderately high (10.1%); it was higher in the Upper Egypt (11.7%) than the Lower Egypt (8.0%) population and more frequent in young adults--especially those of Upper Egypt--and males than females in both populations. The prevalence of anti-HBs gradually increased with age; it was higher in the Lower Egypt (51.1%) than the Upper Egypt (41.7%) population, and it was higher in females than males. A remarkably high infection rate, as shown by the prevalence of anti-HBc, was found in both populations (88.0%), with minor variations depending on age, sex, and geographic area.