Trans-radial Angioplasty of Anomalous Origin of Right Coronary Artery: A Single-Centre Experience.

Successful percutaneous coronary intervention (PCI) to anomalous coronary arteries is technically challenging, particularly through transradial route. The application of appropriate techniques and devices may help overcome these challenges. The objective of this study is to explore the technical and procedural challenges in percutaneous coronary intervention (PCI) of anomalous origin of right coronary artery (AORCA) through the trans-radial route. This prospective study consisted of 25 consecutive patients who underwent PCI for an angiographically significant stenosis in AORCA from November 2017 to May 2019 at Ibrahim Cardiac Hospital & Research Institute (ICHRI). Demographic details and procedural data including numbers of catheters used, access, hardware, techniques, duration of procedure, volume of contrast and complications were recorded and statistically analyzed. The origin of AORCA was 48.0% each from the right and left coronary sinus, with 4.0% arising from the ascending aorta. Among those of right coronary sinus origin, superior take off was 83.3% and inferior take-off was 8.3%, with a further 8.3% originating from the left main, with a common origin with the left anterior descending (LAD) artery, from right coronary sinus. The mean age was 55.8±7.5 years. Diabetics were 84.0%, hypertensive 88.0%, dyslipidemic 68.0% and 20.0% had a history of smoking. Percutaneous coronary intervention (PCI) was performed successfully in 100.0% cases. Transradial access was the default route for coronary angiography in all cases. Angioplasty was performed trans-radially in 92.0% and trans-femoral in 8.0%, for two cases requiring switch over from radial to femoral route. The average number of guide catheters used was (2.0±1.0), (range: 1-4). The guide catheter hooked the coronary ostium selectively in 32.0%, off ostium in 56.0% and deep intubation was done in 12.0% cases. Anchoring wire to enhance guide support was used in 12.0%. 6 Fr guide extension catheter Guidezilla was used in 8.0% cases. The average duration of the procedure was 39.4 (range; 15-90) minutes, the average volume of contrast used was 67.0 (range: 30-150) ml. Average stent length was 28.6 (range; 12-43) mm. For PCI, Judkin's left (JL) and Judkin's Right (JR) were most commonly used guides (36.0% and 28.0% respectively), followed by multipurpose angled (MPA) guide (12.0%). The majority of the lesions stented were of ACC/AHA classification of type B (48.0%) followed by type A (36.0%) and type C (16.0%). Thrombus extraction was performed in a single case. One case was complicated by coronary artery dissection. PCI of AORCA through transradial route is technically challenging but feasible with a reasonable amount of contrast and radiation, and appropriate use of guides and techniques. Proper localization of ostium and selection of suitable guide is the key to success, aided by additional devices in the armamentarium of interventional cardiology such as guide extension catheter and anchoring wires.

Clinical Outcome on Comminuted Femoral Shaft Fractures in Adults Treated by Minimally Invasive Plate Osteosynthesis (MIPO) with Locking Plate.

Intramedullary nailing is a pillar in the treatment of femoral shaft fractures. But it is not possible in all cases especially in comminuted fractures. This study has been designed to explain the importance of Minimally Invasive Plate Osteosynthesis (MIPO) with the locking plate in the treatment of comminuted Femoral Shaft Fracture. Twenty (20) such patients were treated by MIPO and analysis has been done in this study to get fruitful result and to find out the effectiveness of this procedure who were admitted at Mymensingh Medical College Hospital, Mymensingh, a tertiary level hospital of Bangladesh from February 2018 to January 2019. Mean age of the patients were 49.20±14.41 years. Based on AO classification, there were 4, 8 and 8 patients belong to type A, B and C respectively. The union period for all the patients was in between 12 to 14 weeks. The mean union period was 12.90±1.997 weeks. Mean follow up period was 19.70±2.77 weeks. Mean full weight bearing period was 16.50±1.10 weeks. In Thoresen scoring system excellent result was 9(45%), good result was 10(20%) and fair result was 01(5%). Mal-alignment happened in two cases. However, delayed union and broken screws were found in two cases each of which was treated accordingly. Comminuted Femoral shaft fracture with MIPO procedure is more effective treatment than intramedullary nailing. Furthermore, mal-alignment is the basic complexity that must be taken away intraoperatively.

Pterygium in young members of one family.

PURPOSE: To report a family with aggressive, early-onset pterygium. METHODS: We examined all living relatives (with one exception) of a Saudi Arabian family and found three members with pterygium (onset occurred when the patients were at early 20s, 6, and 4 years of age). RESULTS: Multiple attempts at surgical removal, even in conjunction with application of topical mitomycin C and use of conjunctival autograft, failed to prevent recurrent pterygium, which advanced across the visual axis and produced profound visual disability in the three cases. CONCLUSION: Contrary to previously published reports of familial pterygium, two of the three cases had childhood age at onset and all three had an aggressive clinical course after the onset of recurrent pterygium after surgical resection; genetic identification may be beneficial.

Magnetic resonance imaging of the bone marrow in 3 patients with aplastic anemia.

Bone marrow appearances in aplastic anemia are characterized by the abundance of fatty marrow that replaces normal functional marrow. The signal intensity of aplastic bone marrow in sagittal T1-weighted magnetic resonance images of the spine is bright, resembling that of subcutaneous fat and, in most cases, is not difficult to differentiate from normal age-related marrow changes. Three patients with aplastic anemia are described, and the correlation of magnetic resonance imaging of the spine with bone marrow trephine biopsy findings in these patients is portrayed. Magnetic resonance imaging is an accessible, non-invasive technique that allows sampling of a larger volume of bone marrow tissue and is especially useful in the detection of fatty marrow replacement of the normal functional marrow in aplastic anemia.

A study of Protein S antigen levels in 3788 healthy volunteers: influence of age, sex and hormone use, and estimate for prevalence of deficiency state.

Total Protein S (tPS) and free Protein S (fPS) antigen levels were measured in 3788 healthy blood donors. Men had higher levels of both parameters than women (P < 0.001). Age had no effect on tPS in men, although there was a slight reduction in fPS levels with increasing age. In women increasing age was associated with a significant increase in tPS levels (P < 0.001) but had no effect on fPS after adjustment for menopausal state. Oral contraceptive pill (OCP) use significantly lowered tPS but had no effect on fPS. In post-menopausal women, hormone replacement therapy (HRT) use had no statistically significant effect on either tPS or fPS. Donors with tPS or fPS levels in the lowest percentile (n = 56) were retested; only nine with repeat low levels were identified, eight of whom had persistently low levels over a 4-7-year follow-up. Acquired deficiency was excluded. When possible, family studies were performed, leading to an estimate of prevalence of familial PS deficiency of between 0.03% and 0.13% in the general population.

An evaluation of theophylline dosing. Suggested by the Saudi national protocol for children with severe asthma.

OBJECTIVE: To evaluate the impact of Saudi national protocol on the diagnosis and management of asthma for optimizing theophylline use in children with severe asthma. To also review theophylline clearance and provide guidelines for individualization of doses. METHODS: Theophylline level was estimated in blood samples of 66 children with severe asthma who were admitted to King Abdulaziz University Hospital during the period 1998-1999. The theophylline doses given to these patients was reviewed and patients were categorized into 2 groups: Group one had received doses recommended by Saudi national protocol +/- 10%, group 2 had received doses <90% of that recommended by Saudi national protocol. The distribution of theophylline levels in blood samples of each group was estimated. Theophylline steady state level was used to estimate theophylline clearance using a standard pharmacokinetic equation. RESULTS: Out of the total samples from group one, 70% of theophylline levels were within therapeutic range, while only 10% of the total samples of group 2 were within therapeutic range. The mean theophylline clearance in children (1-8 years) was estimated as 0.092 +/- 0.023 and was found significantly higher than the mean theophylline clearance (0.069 +/- 0.014) which is observed in older children (9-13 years). CONCLUSION: Saudi national protocol theophylline dose guidelines had a favorable impact on the optimization of theophylline use in children with severe asthma. Guidelines that ensure accurate adjustment of doses on individual basis in view of drug level were suggested.

Intracorneal hematoma in Mooren ulceration.

PURPOSE: To report a case of intracorneal hematoma occurring in association with Mooren ulceration. METHOD: Case report. RESULTS: In an 81-year-old man with bilateral Mooren ulceration, a dense intracorneal hemorrhage occurred in the right eye secondary to peripheral corneal neovascularization and was followed by slow resolution over a 3-year period. Following subsequent lamellar and penetrating keratoplasty, histopathologic examination demonstrated the association between the stromal neovascularization and the residual interlamellar hemorrhage, as well as phagocytosis of residual hemosiderin by macrophages. CONCLUSION: Intracorneal hematoma with spontaneous resolution has been documented clinically and histopathologically in an eye with Mooren ulceration.

The effect of alpha-thalassemia on cord blood red cell indices and interaction with sickle cell gene.

BACKGROUND: AA+/--thalassemia is known to be prevalent in the Eastern region of Saudi Arabia. There are no large scale reports regarding the effect of alpha-thalassemia on red cell indices of cord blood from Saudi Arabia. Similarly, there are no reports regarding the interaction of AA+/--thalassemia and the sickle cell gene in relation to red cell indices in cord blood. To address these issues, we undertook a study on neonatal cord blood samples. MATERIALS AND METHODS: In a prospective study, cord blood samples from 504 neonates from the Qatif area of the Eastern Province of Saudi Arabia were analyzed for complete blood counts (CBC) and cellulose acetate Hb electrophoresis. Hb S was confirmed by citrate agar Hb electrophoresis. RESULTS: There were 243 case samples with normal Hb electrophoresis (Hb A 27.2+/-7% and Hb F 72.6+/-7.7%). Their mean Hb (g/dL), RBC (x10(12) /L), Hct (%), MCV (fl), MCH (pg), MCHC (g/dL), RDW-SD (fl) and RDWCV (%) were 15.05+/-1.6, 4.5+/-0.5, 47.4+/-5.3, 106+/-8, 33.6+/-2.3, 31.8+/-1.7, 69.2+/-9.5 and 17.9+/-1.7, respectively. There were 136 cases with alpha-thalassemia trait (alphaTT), 57 cases with sickle cell trait (SCT) and 50 cases of sickle cell trait with alpha-thalassemia trait (SCT/alphaTT). There were 10 cases of Hb H disease (6 definite), including one with sickle cell disease (SCD) and two with SCT, Hb Bart's 23.9%-43.6%; four probable with Hb Bart's 10.9%-16.1%, and one with SCT. The effect on red cell parameters in Hb H disease were most pronounced. In addition, there were seven cases of SCD, four of whom had coexistent AA+/--thalassemia trait (SCD/alphaTT). CONCLUSION: The prevalence of alpha-thalassemia in this cohort of Saudi population was 39.99%. Hb H disease appeared as common as SCD. Sickle cell gene was seen in 23.4% of neonatal samples. alpha-Thalassemia gene significantly reduces MCH, MCV, RDW-SD, Hct, Hb, and increases RBC count in both normal or sickle cell trait neonates. Generally, the variation of red cell parameters is directly proportional to the amount of Hb Bart's in the cord blood. Sickle cell gene in itself produces low MCV, RDW-SD and MCH in cord blood. Further, normal reference values for red cell parameters of cord blood are established.

Seroprevalence of hepatitis A virus markers in Eastern Saudi Arabia.

OBJECTIVE: To record and update the sero-epidemiological status of Hepatitis A virus in Eastern Saudi Arabia. To investigate the main viral etiology of clinical hepatitis in children and discuss the possibility of introducing a Hepatitis A virus vaccine in this Province. METHODS: Examining serum specimens by Enzyme Linkage Immuno-Sorbet Assay technique for these parameters: Immunoglobulin M anti-hepatitis A virus, total immunoglobulin anti-hepatitis A virus, and in selected cases we checked for hepatitis B surface antigen and anti-hepatitis C virus. The study was carried out in the Virology Diagnostic Labs, of Dammam Regional Laboratories & Blood Bank, Dammam. A total of 12,357 serum samples were collected from 5876 healthy children, 5798 healthy adults, and 683 from clinically diagnosed hepatitis in children. The period of study was 12 years from February 1987 to January 1999. RESULTS: Hepatitis A virus prevalence showed 3% for pre-school age, 80% in older children and 93% in adults, while total prevalence was 86%. Breaking down the prevalence among children showed 3% in the <6 years age group, 62% in the 6 - <8 years age group, 71% in the 8 - <10 years age group, 83% in the 10 - <12 years age group and 93% in the 12 - <18 years age group. While the grand total among children was 78%. The prevalence of hepatitis viruses causing clinical hepatitis in children showed: 65% for hepatis A virus, 21% for hepatitis B virus, 7% for hepatitis C virus, 2% for double infection of hepatitis B virus + hepatitis C virus and 5% for non A, non B, non C. CONCLUSION: Hepatitis A virus infection starts dramatically high in school-age children, and then rises gradually with an increase in age. This reflects that our region is of pattern I class. There is no difference in the prevalence due to seasons of year, climate or sex. Hepatitis A virus is the leading cause of clinical hepatitis in children, followed by hepatitis B virus and hepatitis C virus. There is a possibility of starting to introduce hepatitis A virus vaccine among pre-school age children, as well as among hepatitis A virus negative adults that live in a higher socioeconomic environment within the country, which can be considered as islands of pattern II among pattern I areas.

Spectrum of hereditary coagulation factor deficiencies in eastern province, Saudi Arabia.

In a 7-year retrospective analysis (1991-97) of the records of the Department of Haematology, Regional Laboratory and Blood Bank (Dammam), 54 patients from all parts of Saudi Arabia's Eastern Province were diagnosed with hereditary coagulation factor deficiencies. The largest group of patients, 42 haemophiliacs, included 4 non-Saudi patients. There were 39 haemophilia A or factor VIII deficiency patients, 2 haemophilia B or factor IX deficiency patients and 1 combined factor VIII and V deficiency patient. There were 5 Saudi patients with probable factor XIII deficiency, and 7 patients, all but one who were Saudi, had von Willebrand disease. The distribution of haemophilia patients in Eastern Province showed some differences compared with those reported from Riyadh and from Western countries. Among Saudis in Eastern Province, the number with suspected factor XIII deficiency, although low, was higher than that reported for other regions. The number of patients with haemophilia B and von Willebrand disease was lower than expected, when compared with the number of haemophilia A cases.

Immunophenotypic pattern of childhood acute lymphoblastic leukemia.

Full text is available as a scanned copy of the original print version.

Prevalence of coxsackieviruses among healthy populations and opthalmic disease patients in the Eastern Province, Saudi Arabia.

Full text is available as a scanned copy of the original print version.

Spectrum of hereditary coagulation factor deficiencies in Eastern Province, Saudi Arabia

In a 7-year retrospective analysis [1991-97] of the records of the Department of Haematology, Regional Laboratory and Blood Bank [Dammam], 54 patients from all parts of Saudi Arabia's Eastern Province were diagnosed with hereditary coagulation factor deficiencies. The largest group of patients, 42 haemophiliacs, included 4 non-Saudi patients. There were 39 haemophilia A or factor VIII deficiency patients, 2 haemophilia B or factor IX deficiency patients and 1 combined factor VIII and V deficiency patient. There were 5 Saudi patients with probable factor XIII deficiency, and 7 patients, all but one who were Saudi, had von Willebrand disease. The distribution of haemophilia patients in Eastern Province showed some differences compared with those reported from Riyadh and from Western countries. Among Saudis in Eastern Province, the number with suspected factor XIII deficiency, although low, was higher than that reported for other regions. The number of patients with haemophilia B and von Willebrand disease was lower than expected, when compared with the number of haemophilia A cases

Positive direct antiglobulin test due to antiphospholipid antibodies in normal healthy blood donors.

OBJECTIVES: Positive direct antiglobulin tests (DAT) occur occasionally, without obvious cause, among normal blood donors. This is sometimes associated with a false-positive serologic test for syphilis. Positive DATs due to antiphospholipid antibodies (APAbs) are well documented in the antiphospholipid syndrome with systemic lupus erythematosus and the primary antiphospholipid syndrome. METHODS: Using conventional haematologic and serologic methods, we tested 474,545 normal blood donors in the west of Scotland during the years 1991 through 1993. RESULTS: We identified 42 normal blood donors with a positive DAT and observed three who had positive DATs and false-positive VDRL tests, all of whom expressed raised APAbs. CONCLUSION: APAbs may be an incidental cause of positive DATs among healthy blood donors.

Isolated familial plasminogen deficiency may not be a risk factor for thrombosis.

Despite many reports of individuals with congenital plasminogen deficiency and thrombosis, there is still uncertainty whether heterozygous deficiency represents a real thrombophilic risk factor or simply a coincidental finding. We have addressed this issue by testing for plasminogen deficiency in a cohort of 9611 blood donors. Out of 66 donors with reduced plasminogen activity on two occasions 28 were shown to have a familial deficiency state (including 3 with dysplasminogenaemia). Our observed prevalence rate for familial plasminogen deficiency, calculated at 2.9/1000 (95% CI = 1.9-4.2 per 1000), was not significantly different from that calculated from published reports of congenital plasminogen deficiency in thrombotic cohorts (5.4/1000). Furthermore, with only two exceptions, all 80 donors and relatives with familial deficiency were asymptomatic with regard to thrombosis-including a 29 year old donor with suspected compound heterozygous hypoplasminogenaemia. These findings add further weight to the argument that familial heterozygous plasminogen deficiency, at least in isolation, does not constitute a significant thrombotic risk factor. However, it remains uncertain whether plasminogen deficiency, when combined with other thrombophilic conditions, may become more clinically important.

Possible interaction between cyclosporine and glibenclamide in posttransplant diabetic patients.

The possible occurrence of a kinetic interaction between cyclosporine A and glibenclamide was assessed by reviewing data of six posttransplant diabetic patients who received the two drugs concurrently. Coadministration of the two drugs resulted in a 57% increase in the steady-state plasma cyclosporine levels despite normal hepatic and renal functions in the patients. This elevation in cyclosporine level is possibly due to an interaction between the two drugs resulting from an inhibition of CYP3A4-mediated metabolism of cyclosporine by glibenclamide. This observation calls for a closer monitoring of cyclosporine plasma levels during concomitant administration of these two drugs in this group of patients.

The impact of long-term cyclosporin-A therapy on hematological and biochemical profile in renal transplant patients.

With over a decade of extensive clinical use of cyclosporin A (CsA), assessment of its long-term safety implications is due. In this study the impact of long-term continuous use of CsA on a number of hematological and biochemical parameters in renal transplant patients was evaluated. Two groups of 13 patients each, one on conventional therapy (azathioprine + prednisolone) and the other on triple therapy (azathioprine + prednisolone + CsA) for 4 to 15 years post-transplantation were compared with respect to their current and overall laboratory values and clinical outcome. Laboratory values were also compared with those of 23 matched healthy subjects. No significant difference in the clinical outcome was found between conventional and triple therapy groups, however, the triple therapy group had significantly less favorable mean values compared to the conventional therapy group with respect to hemoglobin (12.1 +/- 2.2 vs 13.3 +/- 2.1 g/dl, p < 0.02), hematocrit (0.36 +/- 0.06 vs 0.42 +/- 0.03 l/l, p < 0.05), urea (13.0 +/- 3.7 vs 6.7 +/- 4.3 mmol/l, p < 0.01) and uric acid (460.0 +/- 112 vs 330 +/- 88 mumol/l, p < 0.05). The increase in serum uric acid levels in the triple therapy group was progressive throughout the post-transplant period. For the 19 other parameters measured corresponding mean values in the 2 groups were comparable. Mean laboratory values for many parameters in both groups, however, still differed from those in the control group. These results showed that kidney transplant patients on long-term triple therapy have more hematological and biochemical abnormalities and no better clinical outcome than those on conventional therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of protein C deficiency in the healthy population.

Reported prevalence rates for protein C (PC) deficiency in the population at large have varied widely. The differences presumably reflect the existence of an apparently high number of clinically recessive forms of the deficiency. In an attempt to document more precisely the prevalence of PC deficiency in the healthy population we have measured PC activity in just under 10,000 blood donors in the West of Scotland. After repeat testing of donors with low results and then further observation and selection, 32 donors were identified who had individual mean PC activities below the age- and gender-specific study reference range. Assessment of available first degree relatives, and also PC gene analysis in 23 of these donors, allowed identification of at least 14 with an inheritable deficiency (8 by both family study and gene analysis, 3 by family study alone and 3 by gene analysis alone). Two recurring and seven unique point mutations, only one of which has been previously described, were identified. The observed prevalence of inherited PC deficiency was 1.45 per 1000 (95% CI, 0.79/1000 to 2.43/1000). However after correcting for the possibility of missing some genuine inherited deficiencies we estimated the prevalence to be as high as 1 in 500. All cases of hereditary deficiency were asymptomatic with regard to thrombosis and none had a strong family history of thrombosis.(ABSTRACT TRUNCATED AT 250 WORDS)